12-105293RECEIVE PERMIT
Federal Way
COMMUNITY DEVELOPMENT SERNOV 21 201A P P L I CAT I O N
253- 835 -2607• FAX 253 -835 -2609
raanru.cilw)ff ieralu.¢L'ora
CITY OF FEDERAL, WAX
CDS
MF CO ME PL DE EN FP
SITE ADDRESS �
SUITE /UNIT #
PROD T VALUATION
ZONING
ASSESSOR'S TAX /PARCEL #
TYPE OF PERMIT
0 BUILDING D PLUMBING 0 MECHANICAL
0 DEMOLITION 0 ENGIN ERING FIRE PREVENTION
NAME OF PROJECT
(Tenant Name /Homeowner Last Name)
L C
PROJECT DESCRIPTION
Detailed description of work to
1
)CAVAM WV
be included on this permit only
PROPERTY OWNER
`cp
PRIMARY PHONE
MAILIN
E-MAIL
Cl 'f� �\ �
STATE
!20M
MAILIN 3
E -MAIL
CONTRACTOR
C1jTY +
ST TE
WA STATE ONTI�ACTOR'S ]�13 #
�EXPV•I�AvI_ON D
FEDERAL WAY BUSINESS LICENSE N
NAME
PHONE
APPLICANT
(1�a
MAILING ADDRES
E -MAIL
CITY
STATE I
ZIP
FAX
PROJECT CONTACT
(The individual to receive and
respond to all correspondence
N E
�j r1 _ 3 ST
o�- J
MAILING ADDRESS
E -MAIL
concerning this application)
CITY
STATE
ZIP
FAX
ALTERNATE CONTACT NAME:
PHONE
EMAIL
PROJECT FINANCING
NAME
OWNER-FINANCED
Required value of $5,000 or more
(RCW 19.27.095)
MAILING ADDRESS, CITY, STATE, ZIP
PHONE
I certify under penalty of perjury that I am the property owner or authorized agent of the property owner. I certify that to the best
of my knowledge, the information submitted in support of this permit application is true and correct. I certify that I will comply with
all applicable City of Federal Way regulations pertaining to the work authorized by the issuance of a permit. I understand that the
issuance of this permit does not remove the owner's responsibility for compliance with local, state, or federal laws regulating
construction or environmental laws.
I further agree to hold harmless t City of Federal W as to any claim (including costs, expenses, and attorneys' fees Incurred in
the investigation and defense of such latrN hich may a made by any person, including the undersigned, and d against the city,
but only where such claim arises o of th reliance of the city, including its officers and employees, Pon t e accuracy of the
information supplied to the ci as a rt of s appli ation.
}
SIGNATURE: DATE
PRINT NAME:
Bulletin #100 —January 1, 2011 Page 1 of 3 k:�Handouts\Permit Application
UNNE
VALUE OF MECHANICAL WORK $
BATHTUBS (or Tub /shower combo)
(a copy of bid or estimate must be provided)
Indicate how many of each type of xture to be installed or relocated as part of this project. Do not include existing fixtures to remain.
AIR HANDLING UNITS
FANS
GAS PIPE OUTLETS OTHER (Describe)
AIR CONDITIONER
FIREPLACE INSERTS
HOODS (comet mmi)
BOILERS
FURNACES
HOT WATER TANKS (Gas)
COMPRESSORS
GAS LOG SETS
REFRIGERATION SYST
DUCTING
GAS PIPING
WOODSTOVES
WASHING MACHINES
Indicate how many of each type of fixture to be installed or relocated as part of this project. Do not include existing fixtures to remain.
BATHTUBS (or Tub /shower combo)
LAVS (Hand Sinks)
TOILETS
WATER PIPING
DISHWASHERS
RAINWATER SYSTEMS
URINALS
OTHER (Describe)
DRAINS
SHOWERS
VACUUM BREAKERS
DRINKING FOUNTAINS
SINKS (Kitchen /uairy)
WATER HEATERS (Blectric)
HOSE BIBBS
SUMPS
WASHING MACHINES
CRITICAL AREAS ON PROPERTY? I WATER PURVEYOR I SEWER PURVEYOR I VALUE OF EXISTING IMPROVEMENTS
EXISTING /PREVIOUS USE LOT SIZE (In Square Feet) EXISTING FIRE SPRINKLER SYSTEM? PROPOSED FIRE SUPPRESSION SYSTEM?
❑ Yes ❑ No ❑ Yes ❑ No
Bulletin #100 —January 1, 2011 Page 2 of 3 k:\Handouts \Permit Application